Background

Anxiety and its related issues have emerged as one of the most expansive fields of research over the few past decades. Recent studies have revealed that anxiety disorders exhibit the highest prevalence among population, yet it is widely spread among students [1, 2]. Educational experts assert that a moderate level of anxiety can be beneficial as it motivates students to exert more efforts. However, excessive anxiety can have disrupting disorders, one of which is test anxiety (TA). It is defined as a combination of psychological and behavioral responses that occur when there is dread or apprehension about the potential negative outcomes or failure in an exam. Furthermore, test anxiety includes unpleasant feelings and worries in situations when students believe their performance is being assessed as it affects their study habits and academic achievement adversely [2]. Accordingly, these disrupting disorders might hinder performance and impede the ability to demonstrate one’s true abilities during tests [2,3,4]. Multiple studies have uncovered that several factors including being female, and having poor study skills, negative thoughts, distractions, insufficient studying, irregular meal times, difficulty concentrating, and excessive course load; experiencing peers pressure, parental pressures, and challenging test formats; studying all night before exams; worrying about previous exam results; perceiving the course load as heavy; and facing interpersonal issues are closely related to high levels of test anxiety [4,5,6,7,8]. Literature shows that medical education, in particular, is known for its challenging classes and constantly heavy academic workload, multiple assessments throughout the courses, hands on training, and mentoring leading to a stressful environment and thus high rates of depression, test anxiety, poor academic performance, and increased dropouts among medical students [3]. These factors often result in maladaptive behaviors that can negatively impact exam performance and long-term mental and physical well-being of medical students. Test anxiety poses a significant risk to medical students, adversely influencing their professional careers and compromising the quality of the healthcare they provide to their patients owing to their fear of failure as well as distractions [4, 8]. Moreover, literature shows that test anxiety affects medical undergraduate students more than postgraduates as the former ones experienced significantly higher levels of test anxiety in comparison to the latter. In terms of factors that contribute to reducing anxiety, master’s students reported higher levels of confidence, study skills, receiving good grades, and prior knowledge acquired, as compared to undergraduate students. On the other hand, bachelor’s level students tended to attribute test anxiety to factors such as lack of preparation, fear of failure, family responsibilities, professor and exam characteristics, poor time management skills, and inadequate study skills, more than master’s students [9]. Evidence suggested the majority of the medical students lack the appropriate information about exam-taking and anxiety-reduction techniques, and those who know such techniques do not utilize them in real exams [10]. The tendency of students to rely on a multitude of strategies instead of a few well-chosen ones indicates potential inefficiencies that could be addressed through interventions that may involve advisor-guided discussions with students, integrating self-assessment and anxiety management strategies into test-taking courses. However, further research is necessary to explore the effectiveness of such interventions. Providing students and educators with an annotated list of evidence-based strategies would be beneficial in supporting their efforts. Importantly, medical educators should acknowledge and validate test anxiety as a genuine experience, and students would greatly benefit from receiving support from their educators [11]. There was no published data on the prevalence of test anxiety among medical students in Qassim Province. Therefore, this study aimed to determine the prevalence of test anxiety and its causative factors among students at Unaizah College of Medicine.

Methods

Participants

In this cross- sectional study, convenient sampling technique was utilized to collect data from 222 adult male or female medical students studying at Unaizah College of Medicine, Qassim, Saudi Arabia, in 2023. Medical students who provided their informed consents and were studying at Unaizah College of Medicine were included. However, those who were younger than 18 years old, not medical students, or not attending Unaizah College of Medicine and those who have already completed their MBBS or MD degree (graduates) were excluded.

Materials

Online self-administered questionnaire

A validated self-administered online questionnaire, spanning over 4 months, was used to assess the prevalence and factors causing test anxiety among students of Unaizah College of Medicine. The participants were estimated by OpenEpi web tool with a 95% confidence level and 50% prevalence. A P-value of < 0.05 was considered statistically significant.

The questionnaire consisted of distinct parts, and the initial section concentrated on gathering demographic information from the participants. This included gender, generation, marital status, year of study, educational qualifications of the participants’ parents, and monthly income. Generation refers to whether the participant is the first in their family to pursue a career in the medical field (first-generation medical students), or they have family members who are doctors (second-generation medical students). The second section is designed to assess the prevalence of test anxiety, utilizing the Westside Test Anxiety Scale. The third section examined potential risk factors contributing to exam-related anxiety among medical students. These factors included students’ lifestyles, study methods psychological concerns, and examination systems.

Westside test anxiety scale

Students were instructed to rate their responses to the 10 items of the Westside Test Anxiety Scale (WTAS) on a 5-point Likert scale, ranging from 1 (never or not at all true) to 5 (extremely or always true). The total score obtained from the scale was then divided by 10 to determine the level of test anxiety. Based on the guidelines provided by the WTAS, participants who scored below 1.9 were categorized as having low test anxiety, scores between 2.0 and 2.5 indicated normal or average test anxiety, scores between 2.5 and 2.9 indicated high normal test anxiety, scores between 3.0 and 3.4 indicated moderately high anxiety, scores between 3.5 and 3.9 indicated high test anxiety, and scores between 4.0 and 5.0 indicated extremely high anxiety levels.

Statistical package for the social sciences (SPSS) software

Statistical Package for the Social Sciences (SPSS) software was utilized to manage the data and analyze the results with the contribution of data analysis experts. Data was imported from an Excel file into SPSS. Descriptive analysis was performed for all study variables to determine their frequencies and percentages. Cross-tabulation and chi-square tests were used to analyze relationships between text anxiety levels and different sociodemographic characteristics. Logistic regression analysis was emploed to determine significant predictors associated with high anxiety levels among medical students. P-value < 0.05 was considered significant.

Procedures

The study protocol was approved by the university ethical committee. At the beginning of the questionnaire, informed consent was provided to explain the study objectives and the participant’s role in the study if they agreed to volunteer to participate. As stated in the informed consent, the participant’s responses were kept anonymous, and data was only used for the purposes described in the study objectives. Additionally, participants could withdraw from the study at any time.

Background information about studying medicine in Saudi Arabia

As for studying medicine in Saudi Arabia, the medical program spans a duration of 6 years and seamlessly integrates essential concepts from both basic and clinical sciences. The first 3 years are dedicated to comprehensively covering the fundamentals of medical sciences, while the remaining years focus on clinical rotations. During this phase, students venture outside the college environment and actively participate in training at hospitals or primary health care centers. Furthermore, the program adopts a hybrid approach, effectively combining student-centered and teacher-centered activities to facilitate optimal learning. However, one significant aspect that received low ratings from students is the balance between enjoyment and the stress associated with studying medicine. This issue is particularly prevalent among first-year students, indicating the necessity for further research to determine the exact sources of this stress. However, it can be reasonably inferred that the stress experienced is substantial enough to overshadow any enjoyment, underscoring the importance of incorporating healthy extracurricular activities into the curriculum.

Results

The sociodemographic profile of medical students surveyed revealed a majority of females (57.6%) compared to males (42.4%), with a split between first-generation, the first members in their family to join a medical school (38.0%), and second-generation, those whose parents are doctors (62.0%), medical students. Most students were single (97.6%), while a minimal percentage were married (1.5%) or divorced (1.0%). Academic distribution across years included the highest representation in the MD4 (19.5%), the lowest in the MD1 (16.1%), and pre-med (23.4%). Concerning parental education, a significant number of fathers held bachelor’s degrees (46.3%), while mothers had similar educational qualifications, with 42.0% holding bachelor’s degrees. Income distribution reflected that nearly a third of students earned less than 10,000 SR monthly (29.3%), followed by 24.4% earning more than 25,000 SR per month , and a relatively smaller portion falling within the other income brackets (Table 1).

Table 1 Sociodemographic characteristics of the medical students
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The study delved into factors contributing to exam anxiety among students, revealing prevalent concerns across various domains. The examination of lifestyle and study styles highlighted that a significant proportion experienced moderate-to-low self-esteem during exams (87.3%), with the majority reporting average levels (52.2%). Social support was moderately prevalent (43.4%), but poor support affected 16.1% of students. Examination types were predominantly a mix of both oral and written formats (47.8%), with written exams slightly more common (44.4%). Anxiety levels fluctuated among students, with 33.2% experiencing increased anxiety since the year before and 36.1% reporting consistent levels. Factors exacerbating anxiety encompassed extensive course loads (94.1%), negative thoughts and self-criticism (77.1%), and inadequate time for physical activities during exams (75.6%). However, confidence building such as having a study plan (86.3%), time management (92.2%), and receiving good grades (94.6%) was reported to reduce anxiety. A notable 60.5% of participants found anxiety-reducing techniques helpful, while 82.4% believed professors’ teaching methods could influence anxiety level before exams. Among those who practiced (n = 124) anxiety-reducing techniques, positive thinking was the most commonly utilized technique to reduce anxiety (31.5%), followed by breathing deeply (25.0%), exercise (23.4%), and entertainment (21.0%). Additionally, a portion of students disclosed diagnoses of anxiety (21.5%), depression (12.2%), social phobia (3.9%), and personality disorder (2.4%), while the majority (72.2%) reported no diagnoses (Table 2).

Table 2 Factors causing exam anxiety related to students’ lifestyles, study styles, psychological problems, and examination system
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The Westside Test Anxiety Scale evaluated test anxiety levels among participants, revealing a varied distribution across categories. A quarter of respondents reported comfortably low anxiety (25.4%), while a similar proportion fell within the normal or average range (20.0%). High normal anxiety was reported by 14.1%, with moderately high anxiety levels noted among 19.0%. A smaller portion reported high (7.3%) and extremely high (7.3%) levels of test anxiety, reflecting a spectrum from low to significantly elevated anxiety levels among the surveyed individuals (Figure 1). The participants’ test anxiety scores, gauged by the Westside Test Anxiety Scale, were categorized into three main groups for enhanced representability. These groups were delineated as follows: low-test anxiety (1.0–2.5), moderate-test anxiety (2.6–3.4), and high-test anxiety (3.5–5.0) ranges. This stratification aimed to provide a clearer understanding of the distribution and intensity of test anxiety among the surveyed individuals. The analysis showed that a notable portion experienced low anxiety levels (45.4%), followed by moderate anxiety levels reported by 33.2% of respondents. A smaller yet significant proportion reported high anxiety levels (21.5%).

Fig. 1
figure 1

Distribution of test anxiety level among medical students

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The analysis of test anxiety levels based on various sociodemographic characteristics is shown in Table 3. Gender exhibited a noteworthy correlation with anxiety levels (p = 0.003), with females reporting higher proportions of moderate and low anxiety compared to males. However, other factors such as the generation of medical students, marital status, academic year, fathers’ and mothers’ educational levels, and monthly incomes did not exhibit statistically significant associations with anxiety levels (p > 0.05).

Table 3 Relationship of text anxiety level based on different sociodemographic characteristics
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The logistic regression analysis unveiled several significant predictors associated with high anxiety levels among the participants (Table 4). Gender emerged as a prominent factor, with females showing notably higher odds of experiencing high anxiety (odds ratio = 19.05, p = 0.002). Additionally, the participants reporting poor social support exhibited increased odds of high anxiety (odds ratio = 2.56, p = 0.042). Other significant predictors of heightened anxiety levels included the perception of increased anxiety since the year before (odds ratio = 5.94, p = 0.004) and facing frequent tests (odds ratio = 10.58, p = 0.009). Conversely, certain factors such as studying all night before (odds ratio = 0.10, p = 0.046) and a history of no psychological problems (odds ratio = 0.41, p = 0.049) showed lower odds associated with high anxiety.

Table 4 Logistic regression for predicting risk factors of high anxiety
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Discussion

Understanding the prevalence of test anxiety provides crucial insight into the mental health challenges students face within a rigorous academic environment. It sheds light on the specific stressors that can influence students’ well-being, affecting their academic performance and overall quality of life. To start with, there is an apparent gender disparity in reported anxiety levels, with females exhibiting higher proportions of moderate and low anxiety compared to males. Both correlation analysis and logistic regression suggest that being female significantly increases the likelihood of experiencing high anxiety levels. This aligns with existing research that often indicates higher anxiety levels among females in various contexts [12,13,14,15]. The analysis indicated that various sociodemographic factors such as generation, marital status, academic year, parental education levels, and income did not show statistically significant associations with anxiety levels. This suggests that in this study, these factors might not directly influence the reported anxiety levels among participants. However, it is important to interpret these findings cautiously due to several limitations inherent in the study. Actually, identifying the factors causing test anxiety enables the development of targeted interventions. By knowing what specific elements contribute to anxiety, educators and mental health professionals can design support programs, coping strategies, and interventions to help students manage and mitigate test anxiety effectively.

The logistic regression analysis revealed several predictors significantly associated with high anxiety levels. These include poor social support, increased anxiety perception compared to the previous year, facing frequent tests, and a history of psychological problems. Participants reporting poor social support exhibited increased odds of high anxiety. This finding aligns with established research indicating that social support acts as a protective factor against anxiety [16, 17]. A strong social support network provides individuals with emotional, informational, and instrumental assistance, buffering the impact of stressors and reducing anxiety levels [18, 19]. This consistency with prior studies adds credibility to the importance of social support in anxiety management among medical students [20,21,22]. While the study identified a correlation between poor social support and heightened anxiety, it does not establish the direction of causality. It is plausible that individuals experiencing high anxiety may inadvertently withdraw or face challenges in seeking and maintaining social connections, leading to a perception of poor support.

Another important finding in this study was that those who perceived an increase in anxiety since the previous year were more likely to experience high anxiety. This could suggest a pattern of escalating anxiety levels among the participants and also hints at the temporal aspect of anxiety levels, suggesting that some individuals might experience a progressive increase in anxiety over time [23]. Understanding the temporal dynamics of anxiety is critical in identifying and addressing early signs of escalating anxiety, potentially allowing for timely interventions. However, it is essential to explore whether an actual increase in anxiety triggers high anxiety levels or if high anxiety leads to a heightened perception of anxiety, potentially creating a cyclical pattern that exacerbates the condition. Facing frequent tests was significantly associated with higher anxiety levels, indicating a potential stressor in the academic environment. Evidence shows that high-stakes assessments, especially when frequent, can induce performance pressure, fear of failure, and a constant need for academic achievement, contributing to heightened anxiety levels [24,25,26]. Surprisingly, studying all night before was associated with lower odds of high anxiety. This might be an unexpected finding and warrants further investigation. Also, it is crucial to consider the subjective perception of anxiety. Students who engage in extensive studying might perceive themselves as better prepared, potentially reducing their anxiety about the impending test or academic evaluation [27]. Additionally, students who possess effective study habits, better time management skills, or lower baseline anxiety might be more likely to stay up all night to study, contributing to the observed association [28]. Participants with no history of psychological problems had lower odds of experiencing high anxiety. Individuals without a history of psychological problems might possess inherent resilience or coping mechanisms that render them less susceptible to experiencing high levels of anxiety [29]. This resilience could stem from adaptive coping strategies, strong support systems, or a more robust mental health foundation [30].

Strength and limitations

This study had several strengths that contributed to its robustness. Firstly, its cross-sectional design allowed for a snapshot view of anxiety levels among participants at a specific point in time, providing valuable insights into this aspect of their experience. Moreover, the inclusion of both male and female students across various academic years in medical school broadened the study’s scope, offering a more comprehensive understanding of anxiety prevalence. The questionnaire’s thoroughness ensured that a wide range of relevant factors influencing anxiety could be explored, enhancing the depth of the study. Lastly, the use of the Westside Test Anxiety Scale, a recognized and reliable method for evaluating anxiety levels, added credibility and accuracy to the findings.

The lack of statistically significant associations between sociodemographic factors like generation, marital status, academic year, parental education levels, and income with anxiety levels might stem from constraints within the research design. The study’s sample size, potentially limited diversity within demographics, and the complexity of anxiety determinants could have obscured potential relationships. The study relied on self-reported data related to factors influencing anxiety, study patterns and history of psychological problems, which could be subject to recall bias or underreporting. Moreover, the tools used to measure anxiety and sociodemographic characteristics might not have been sufficiently sensitive or comprehensive. These limitations suggest a need for more robust methodologies, larger and more diverse samples, and a broader consideration of factors influencing anxiety levels in future research endeavors.

Conclusions

Findings from this study can influence institutional policies related to students’ well-being. Colleges can develop policies or allocate resources to create supportive environments that address the factors leading to test anxiety, promoting mental health and academic success. It enriches the body of knowledge on mental health in educational settings, potentially paving the way for further studies, comparisons across institutions, and international perspectives. Highlighting the prevalence of test anxiety raises awareness among educators, students, and parents about the challenges students face. Thus, it could promote a deeper understanding of the importance of mental health support within academic settings and encourage open discussions about coping mechanisms and seeking help when needed.